<html><body><center>
<table> 
	<tr>
		<td> 
			<img src="left.jpg" />
		</td>
		<td width="700" valign=top align=center background="orderBG2.jpg">
			<form action="https://www.sandbox.paypal.com/webapps/adaptivepayment/flow/pay">
			
			<table> 
				<tr> 
					<td>
						<center><h1><u>ORDER NOW!</u></h1></center>
					</td>
				</tr>
				<tr>
					<td><center>
						<table>
							<tr bgcolor=black>
								
								<td>
									<font color="white">Description</font>
								</td>
								<td>
									
									<font color="white">Amount</font>
								</td>
								<td>
									<font color="white">Price per unit</font>
								</td>
								</font>
							</tr>
							<tr>
								<td>
									Smart-Blast speaker
								</td>
								<td>
									<select>
									  <option value="1">1</option>
									  <option value="2">2</option>
									  <option value="3">3</option>
									  <option value="4">4</option>
									  <option value="5">5</option>
									  <option value="6">6</option>
									  <option value="7">7</option>
									  <option value="8">8</option>
									  <option value="9">9</option>
									  <option value="10">10</option>
									</select>
								</td>
								<td>
									150$
								</td>
							</tr>
						</table></center>
					</td>
				</tr>
				<tr>
					<td widht="100%">
						<table>
							<tr>
								<td>
									<b>First Name:</b>
								</td>
								<td>
									<input type="text" name="fname" /> 
								</td>
					
								<td>
									<b>Last Name:</b>
								</td>
								<td>
									<input type="text" name="lname" /> 
								</td>
							</tr>
							<tr>
								<td>
									<b>Phone no.:</b>
								</td>
								<td>
									<input type="text" name="phone" /> 
								</td>
					
								<td>
									<b>City:</b>
								</td>
								<td>
									<input type="text" name="city" /> 
								</td>
							</tr>
							<tr>
								<td>
									<b>Address:</b>
								</td>
								<td>
									<input type="text" name="address" /> 
								</td>
							</tr>
						</table>
					</td>
					<td>
						<table>
							<tr>
								<td>
								</td>
							</tr>
						</table>
					</td>
				</tr>
				<tr>
					<td>
						<input type="image" action="submit" id="submitBtn" value="Pay with PayPal" src="paypal.gif">
						</form>
						<script type="text/javascript" charset="utf-8">
						var embeddedPPFlow = new PAYPAL.apps.DGFlow({trigger: 'submitBtn'});
						</script>
					</td>
			</table>
		</td>
		<td>
			<img src="right.jpg" />
		</td>
	</tr>
</table></center>
</body></html>